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Cervical insufficiency (premature cervical dilatation)

a variable condition whereby expulsion of the products of conception occurs. It is thought to be related to tissue changes and alterations in the length of the cervix

Severe preeclampsia

consists of blood pressure that is 160/110 mm Hg or greater, proteinuria greater than 3+, oliguria (small amounts of urine), elevated serum creatinine greater than 1.1 mg/dL, cerebral or visual disturbances (headache and blurred vision), hyperreflexia with possible ankle clonus, pulmonary or cardiac involvement, extensive peripheral edema, hepatic dysfunction, epigastric and right upper‑quadrant pain, and thrombocytopenia (deficiency of platelets in the blood)

Mild preeclampsia

is GH with the addition of proteinuria of greater than or equal to 1+. Report of transient headaches might occur along with episodes of irritability. Edema can be present.

HELLP syndrome

is a variant of GH in which hematologic conditions coexist with severe preeclampsia involving hepatic dysfunction. HELLP syndrome is diagnosed by laboratory tests, not clinically. ● H: Hemolysis resulting in anemia and jaundice ● EL: Elevated liver enzymes resulting in elevated alanine aminotransferase (ALT) or aspartate transaminase (AST), epigastric pain, and nausea and vomiting ● LP: Low platelets (less than 100,000/mm3), resulting in thrombocytopenia, abnormal bleeding and clotting time, bleeding gums, petechiae, and possibly disseminated intravascular coagulopathy (DIC)

Hyperemesis gravidarum

is excessive nausea and vomiting (possibly related to elevated hCG levels) that is prolonged past 12 weeks of gestation and results in a 5% weight loss from prepregnancy weight, electrolyte imbalance, acetonuria (excretion in the urine of excessive amounts of acetone, an indication of incomplete oxidation of large amounts of fat, and common in diabetic acidosis), and ketosis (bodyuses fat deposits as energy source). ● There is a risk to the fetus for intrauterine growth restriction (IUGR) or preterm birth if the condition persists

Eclampsia

is severe preeclampsia manifestations with the onset of seizure activity or coma. Eclampsia is usually preceded by headache, severe epigastric pain, hyperreflexia, and hemoconcentrations, which are warning signs of probable convulsions.

Iron‑deficiency anemia

occurs during pregnancy due to inadequacy in maternal iron stores and consuming insufficient amounts of dietary iron.

Gestational hypertension (GH)

which begins after the 20th week of pregnancy, describes hypertensive disorders of pregnancy whereby the woman has an elevated blood pressure at 140/90 mm Hg or greater recorded on two different occasions, at least 4 hr. apart. There is no proteinuria. The presence of edema is no longer considered in the definition of hypertensive disease of pregnancy. Blood pressure returns to baseline by 6 weeks postpartum.

A nurse is caring for a client who has suspected hyperemesis gravidarum and is reviewing the client's laboratory reports. Which of the following findings is a manifestation of this condition? A. Hgb 12.2 g/dL B. Urine ketones present C. Alanine aminotransferase 20 IU/L D. Serum glucose 114 mg/dL

A. Altered hematocrit is a manifestation of hyperemesis gravidarum due to the hemoconcentration that occurs with dehydration. B. CORRECT: The presence of ketones in the urine is associated with the breakdown of proteins and fats that occurs in a client who has hyperemesis gravidarum. C. Liver enzymes are elevated in a client who has hyperemesis gravidarum. This finding is within the expected reference range. D. Decreased serum glucose is anticipated in a client who has hyperemesis gravidarum. This result is within the expected reference range.

A nurse is administering magnesium sulfate IV to a client who has severe preeclampsia for seizure prophylaxis. Which of the following indicates magnesium sulfate toxicity? (Select all that apply.) A. Respirations less than 12/min B. Urinary output less than 30 mL/hr C. Hyperreflexic deep-tendon reflexes D. Decreased level of consciousness E. Flushing and sweating

A. CORRECT: A respiratory rate less than 12/ min is a sign of magnesium sulfate toxicity. B. CORRECT: Urinary output less than 30 mL/hr is a sign of magnesium sulfate toxicity. C. The absence of patellar deep-tendon reflexes is a sign of magnesium sulfate toxicity. D. CORRECT: Decreased level of consciousness is a sign of magnesium sulfate toxicity. E. Flushing and sweating are adverse effects of magnesium sulfate but are not signs of toxicity

A nurse is caring for a client who is at 14 weeks of gestation and has hyperemesis gravidarum. The nurse should identify that which of the following are risk factors for the client? (Select all that apply.) A. Obesity B. Multifetal pregnancy C. Maternal age greater than 40 D. Migraine headache E. Oligohydramnios

A. CORRECT: Obesity is a risk factor for hyperemesis gravidarum. B. CORRECT: Multifetal pregnancy is a risk factor for hyperemesis gravidarum. C. Maternal age less than 30 is a risk factor for hyperemesis gravidarum. D. CORRECT: Migraine headache is a risk factor for hyperemesis gravidarum. E. Oligohydramnios is not a risk factor for hyperemesis gravidarum.

A nurse is reviewing a new prescription for ferrous sulfate with a client who is at 12 weeks of gestation. Which of the following statements by the client indicates understanding of the teaching? A. "I will take this pill with my breakfast." B. "I will take this medication with a glass of milk." C."I plan to drink more orange juice while taking this pill." D."I plan to add more calcium-rich foods to my diet while taking this medication."

A. Ferrous sulfate should be taken on an empty stomach. B. Milk will decrease the absorption of ferrous sulfate. C. CORRECT: A diet with increased vitamin C improves the absorption of ferrous sulfate. D. Although a diet of calcium-rich foods is appropriate for the client during pregnancy, it does not improve the effectiveness of ferrous sulfate.

A nursing is caring for a client who is receiving IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if magnesium sulfate toxicity is suspected? A. Nifedipine B. Pyridoxine C. Ferrous sulfate D. Calcium gluconate

A. Nifedipine is an antihypertensive medication that can be administered to women who have gestational hypertension. B. Pyridoxine (vitamin B6) is a vitamin supplement prescribed for clients who have hyperemesis gravidarum. C. Ferrous sulfate is a medication used in the treatment of iron deficiency anemia. D. CORRECT: Calcium gluconate is the antidote for magnesium sulfate.

A nurse is preparing to teach a client who is at 20 weeks of gestation and is scheduled to undergo a prophylactic cervical cerclage. What information should the nurse include in the teaching? DESCRIPTION OF PROCEDURE POTENTIAL COMPLICATIONS: Identify two. CLIENT EDUCATION: Describe at least four instructions to give the client.

DESCRIPTION OF PROCEDURE: Surgical reinforcement of the cervix with a heavy ligature (suture) that is placed submucosally around the cervix to strength it and prevent premature cervical dilation. POTENTIAL COMPLICATIONS ● Uterine contractions ● Rupture of membranes ● Infection CLIENT EDUCATION ● Remain on activity restrictions/bed rest as prescribed. ● Increase hydration to promote a relaxed uterus. ● Refrain from sexual intercourse. ● Clinical findings to report to the provider: preterm labor, rupture of membranes, signs of infection, strong contractions less than 5 min apart, perineal pressure, and the urge to push. ● Use of home uterine activity monitor. ● Home health agency to follow up. ● Plan for removal of the cerclage at 37 weeks of gestation.

Iron‑deficiency anemia MEDICATIONS

Ferrous sulfate iron supplements CLIENT EDUCATION ● Instruct the client to take the supplement on an empty stomach and take with orange juice to increase absorption. ● Encourage a diet rich in vitamin C-containing foods to increase absorption. ● Suggest that the client increase roughage and fluid intake in diet to assist with discomforts of constipation. Iron dextran Used in the treatment of iron-deficiency anemia when oral iron supplements cannot be tolerated by the client who is pregnant.

Gestational diabetes mellitus EXPECTED FINDINGS

Hypoglycemia: nervousness, headache, weakness, irritability, hunger, blurred vision, tingling of mouth or extremities Hyperglycemia: polydipsia (thirst), polyphagia (hunger), polyuria (urine), nausea, abdominal pain, flushed dry skin, fruity breath PHYSICAL ASSESSMENT FINDINGS ● Hypoglycemia ● Shaking ● Clammy pale skin ● Shallow respirations ● Rapid pulse ● Hyperglycemia ● Vomiting ● Excess weight gain during pregnancy

Gestational diabetes mellitus MEDICATIONS

In contrast to women who have type I diabetes mellitus, women who have GDM are managed initially with diet and exercise alone. If glucose levels are persistently high, insulin is begun. Oral hypoglycemic therapy is an alternative to insulin in women who have GDM who require medication in addition to diet for blood glucose control. Most oral hypoglycemic agents are contraindicated for gestational diabetes mellitus, but there is limited use of glyburide. The provider will need to make the determination if these medications can be used.

Cervical insufficiency (premature cervical dilatation) EXPECTED FINDINGS

Increase in pelvic pressure or urge to push PHYSICAL ASSESSMENT FINDINGS ● Pink-stained vaginal discharge or bleeding ● Possible gush of fluid (rupture of membranes) ● Uterine contractions with the expulsion of the fetus ● Postoperative (cerclage) monitoring for uterine contractions, rupture of membranes, and signs of infection

Gestational hypertension (GH) MEDICATIONS

It is recommended that daily low dose aspirin therapy be initiated late in the first trimester for women who have a history of early onset preeclampsia. ANTIHYPERTENSIVE MEDICATIONS ● Methyldopa ● Nifedipine ● Hydralazine ● Labetalol ● Avoid ACE inhibitors and angiotensin II receptor blockers.

Gestational hypertension (GH) ANTICONVULSANT MEDICATIONS:

Magnesium sulfate ● Medication of choice for prophylaxis or treatment to lower blood pressure and depress the CNS. ● Nursing Considerations ◯ Use an infusion control device to maintain a regular flow rate. ◯ Inform the client that she can initially feel flushed, hot, and sedated with the magnesium sulfate bolus. ◯ Monitor blood pressure, pulse, respiratory rate, deeptendon reflexes, level of consciousness, urinary output (indwelling urinary catheter for accuracy), presence of headache, visual disturbances, epigastric pain, uterine contractions, and fetal heart rate and activity. ◯ Place the client on fluid restriction of 100 to 125 mL/hr, and maintain a urinary output of 30 mL/hr or greater. ◯ Monitor for signs of magnesium sulfate toxicity. ■ Absence of patellar deep tendon reflexes ■ Urine output less than 30 mL/hr ■ Respirations less than 12/min ■ Decreased level of consciousness ■ Cardiac dysrhythmias ◯ If magnesium toxicity is suspected: ■ Immediately discontinue infusion. ■ Administer antidote calcium gluconate or calcium chloride. ■ Prepare for actions to prevent respiratory or cardiac arrest.

Hyperemesis gravidarum PATIENT-CENTERED CARE

NURSING CARE ● Monitor I&O. ● Assess skin turgor and mucous membranes. ● Monitor vital signs. ● Monitor weight. ● Have the client remain NPO for 24 to 48 hr. MEDICATIONS ● Give the client IV lactated Ringer's for hydration. ● Give pyridoxine (vitamin B6) and other vitamin supplements as tolerated. American Congress of Obstetricians and Gynecologists recommend the use of pyridoxine alone or in combination with doxylamine as the initial medication management because these medications are considered both safe and effective. ● Use antiemetic medications (ondansetron, metoclopramide) cautiously for uncontrollable nausea and vomiting. ● Use corticosteroids to treat refractory hyperemesis gravidarum

Gestational hypertension (GH) RISK FACTO RS

No single profile identifies risks for gestational hypertensive disorders, but some high risks include the following. ● Maternal age younger than 19 or older than 40 years ● First pregnancy ● Morbid obesity ● Multifetal gestation ● Chronic renal disease ● Chronic hypertension ● Familiar history of preeclampsia ● Diabetes mellitus ● Rheumatoid arthritis ● Systemic lupus erythematosus

Hyperemesis gravidarum CLIENT EDUCATION DISCHARGE INSTRUCTIONS

● Advance the client to clear liquids after 24 hr if no vomiting. ● Advance the client's diet as tolerated, with frequent small meals. Start with dry toast, crackers, or cereal; then move to a soft diet; and finally to a normal diet as tolerated. ● In severe cases, or if vomiting returns, enteral nutrition per feeding tube or total parental nutrition can be considered.

Cervical insufficiency (premature cervical dilatation) DIAGNOSTIC AND THERAPEUTIC PROCEDURES

● An ultrasound showing a short cervix (less than 25 mm in length), presence of cervical funneling (beaking), or effacement of the cervical os indicates reduced cervical competence. ● Prophylactic cervical cerclage (placement of stitches in the cervix to hold it closed. In select cases, this procedure is used to keep a weak cervix (incompetent cervix) from opening early) is the surgical reinforcement of the cervix with a heavy ligature that is placed submucosally around the cervix to strengthen it and prevent premature cervical dilation. Best results occur if this is done at 12 to 14 weeks of gestation. The cerclage is removed at 37 weeks of gestation or when spontaneous labor occurs.

Gestational hypertension (GH) NURSING CARE

● Assess level of consciousness. ● Obtain pulse oximetry. ● Monitor urine output, and obtain a clean-catch urine sample to assess for proteinuria. ● Obtain daily weights. ● Monitor vital signs with careful attention to blood pressure measurement (e.g., using proper size cuff and avoiding talking to client during measurement). ● Encourage lateral positioning. ● Perform NST and daily kick counts. ● Instruct the client to monitor I&O.

Gestational diabetes mellitus DIAGNOSTIC PROCEDURES

● Biophysical profile to ascertain fetal well-being ● Amniocentesis with alpha-fetoprotein (detect spina bifida and down syndrome) ● Nonstress test to assess fetal well-being

Gestational hypertension (GH) DIAGNOSTIC PROCEDURES

● Dipstick testing of urine for proteinuria ● 24-hr urine collection for protein and creatinine clearance ● Nonstress test, contraction stress test, biophysical profile, and serial ultrasounds to assess fetal status ● Doppler blood flow analysis to assess fetal well-being

Gestational hypertension (GH) ABNORMAL LABORATORY FINDINGS

● Elevated liver enzymes (LDH, AST) ● Increased creatinine ● Increased plasma uric acid ● Thrombocytopenia (decreased in platelets) ● Decreased Hgb ● Hyperbilirubinemia (too much bilirubin in the blood)

Cervical insufficiency (premature cervical dilatation) PATIENT-CENTERED CARE NURSIN G CARE

● Evaluate the client's support systems and availability of assistance if activity restrictions or bed rest are prescribed. ● Assess vaginal discharge. ● Monitor client reports of pressure and contractions. ● Check vital signs. MEDICATIONS Administer tocolytics prophylactically to inhibit uterine contractions

Hyperemesis gravidarum PHYSICAL ASSESSMENT FINDINGS

● Excessive vomiting for prolonged periods ● Dehydration with possible electrolyte imbalance ● Weight loss ● Increased pulse rate ● Decreased blood pressure ● Poor skin turgor and dry mucous membranes

Iron‑deficiency anemia EXPECTED FINDIN GS

● Fatigue and weakness ● Irritability ● Headache ● Feeling dizzy or lightheaded ● Shortness of breath with exertion ● Palpitations ● Craving unusual food (pica) PHYSICAL ASSESSMENT FINDINGS ● Pallor ● Brittle nails ● Shortness of breath

Iron‑deficiency anemia LABORATORY TESTS

● Hgb less than 11 mg/dL in the first and third trimesters and less than 10.5 mg/ ● Hct less than 3%

Gestational hypertension (GH) PHYSICAL ASSESSMENT FINDINGS

● Hypertension ● Proteinuria ● Periorbital, facial, hand, and abdominal edema ● Pitting edema of lower extremities ● Vomiting ● Oliguria ● Hyperreflexia ● Scotoma ● Epigastric pain ● Right upper quadrant pain ● Dyspnea ● Diminished breath sounds ● Seizures ● Jaundice ● Signs of progression of hypertensive disease with indications of worsening liver involvement, kidney failure, worsening hypertension, cerebral involvement, and developing coagulopathies

Gestational hypertension

● Hypertensive disease in pregnancy is divided into clinical subsets of the disease based on end-organ effects and progresses along a continuum from mild gestational hypertension; mild and severe preeclampsia; eclampsia; and hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome. ● Vasospasm contributing to poor tissue perfusion is the underlying mechanism for the manifestations of pregnancy hypertensive disorders. ● Gestational hypertensive disease and chronic hypertension can occur simultaneously. ● Gestational hypertensive diseases are associated with placental abruption, kidney failure, hepatic rupture, preterm birth, and fetal and maternal death.

Gestational diabetes mellitus CLIENT EDUCATION

● Instruct the client to perform daily kick counts. ● Educate the client about diet, including standard diabetic diet and restricted carbohydrate intake. Dietary counseling by a registered dietitian should occur. ● Educate the client about exercise. ● Instruct the client about self-administration of insulin. ● Educate the client about the need for postpartum laboratory testing to include OGTT and blood glucose levels

Iron‑deficiency anemia RISK FACTO RS

● Less than 2 years between pregnancies ● Heavy menses ● Diet low in iron ● Multifetal gestation ● Vomiting frequently due to morning sickness

Gestational hypertension (GH) LABORATORY TESTS

● Liver enzymes ● Serum creatinine, BUN, uric acid, and magnesium increase as renal function decreases ● CBC ● Clotting studies ● Chemistry profile

Gestational hypertension (GH) CLIENT EDUCATION DISCHARGE INSTRUCTIONS

● Maintain the client on bed rest and encourage side-lying position. ● Promote diversional activities (e.g., TV, visits from family or friends, gentle exercise). ● Have the client avoid foods that are high in sodium. ● Have the client avoid alcohol and tobacco and limit caffeine intake. ● Instruct the client to drink six to eight 8-ounce glasses of water a day. ● Maintain a dark quiet environment to avoid stimuli that can precipitate a seizure. ● Maintain a patent airway in the event of a seizure. ● Administer antihypertensive medications as prescribed.

Hyperemesis gravidarum RISK FACTORS

● Maternal age younger than 30 years ● History of migraines ● Obesity ● First pregnancy ● Multifetal gestation ● Gestational trophoblastic disease or fetus with chromosomal anomaly ● Psychosocial issues and high levels of emotional stress ● Clinical hyperthyroid disorders ● Diabetes ● Gastrointestinal disorders ● Family history of hyperemesis

Gestational diabetes mellitus NURSING CARE

● Monitor the client's blood glucose. ● Monitor the fetus.

Gestational diabetes mellitus RISK FACTORS

● Obesity ● Hypertension ● Glycosuria ● Maternal age older than 25 years ● Family history of diabetes mellitus ● Previous delivery of an infant that was large or stillborn

Cervical insufficiency (premature cervical dilatation) CLIENT EDUCATION DISCHARGE INSTRUCTIONS

● Place the client on activity restriction or bed rest. ● Encourage hydration to promote a relaxed uterus. (Dehydration stimulates uterine contractions.) ● Advise the client to avoid intercourse, tampons, and douching, and to monitor for cervical/uterine changes. ● The client can require cervical cerclage (indicated for women who have singleton pregnancy), often placed at 12 to 14 weeks gestation and removed at 37 weeks gestation HEALTH PROMOTION AND DISEASE PREVENTION ● Provide education about clinical findings to report to the provider for preterm labor, rupture of membranes, infection, strong contractions less than 5 min apart, severe perineal pressure, and an urge to push. ● Instruct the client about using the home uterine activity monitor to evaluate uterine contractions. NURSING ACTIONS ● Arrange for the client to follow up with a home health agency for close observation and supervision. ● Plan for removal of the cerclage around 37 weeks of gestation.

Gestational diabetes mellitus LABORATORY TESTS

● Routine urinalysis with glycosuria ● Glucola screening test/1-hr glucose tolerance test: 50 goral glucose load, followed by plasma glucose analysis 1 hr later performed at 24 to 28 weeks of gestation; fasting not necessary; a positive blood glucose screening is 130 to 140 mg/dL or greater; additional testing with a 3-hr oral glucose tolerance test (OGTT) is indicated ● Oral glucose tolerance test following overnight fasting, avoidance of caffeine, and abstinence from smoking for 12 hr prior to testing; a fasting glucose is obtained, a 100 g glucose load is given, and serum glucose levels are determined at 1, 2, and 3 hr following glucose ingestion ● Presence of ketones in urine to assess severity of ketoacidosis

Gestational hypertension (GH) EXPECTED FINDINGS

● Severe continuous headache ● Nausea ● Blurring of vision ● Flashes of lights or dots before the eyes

Gestational diabetes mellitus INCREASED RISKS TO FETUS

● Spontaneous abortion, related to poor glycemic control ● Infections (urinary and vaginal), related to increased glucose in the urine and decreased resistance because of altered carbohydrate metabolism ● Hydramnios, which can cause overdistention of the uterus, premature rupture of membranes, preterm labor, and hemorrhage ● Ketoacidosis from diabetogenic effect of pregnancy (increased insulin resistance), untreated hyperglycemia, or inappropriate insulin dosing ● Hypoglycemia, caused by overdosing in insulin, skipped or late meals, or increased exercise ● Hyperglycemia, which can cause excessive fetal growth (macrosomia)

Iron‑deficiency anemia NURSING CARE

● The recommended iron intake for pregnant women is 27 mg/day. Prenatal vitamins typically contain 30 mg iron. If maternal iron deficiency anemia is present, increased dosages of 60 to 120 mg/day can be required. ● Increase dietary intake of foods rich in iron (legumes, fruit, green leafy vegetables, and meat). ● Educate the client about ways to minimize gastrointestinal adverse effects.

Hyperemesis gravidarum LABORATORY TESTS

● Urinalysis for ketones and acetones (breakdown of protein and fat) is the most important initial laboratory test: Elevated urine specific gravity ● Chemistry profile revealing electrolyte imbalances ◯ Sodium, potassium, and chloride reduced from low intake ◯ Metabolic acidosis (secondary to starvation) ◯ Metabolic alkalosis due to excessive vomiting ◯ Elevated liver enzymes ◯ Bilirubin level (High levels could mean liver cells are not releasing the bilirubin - eventually resulting in jaundice) ● Thyroid test indicating hyperthyroidism. ● Complete blood count (CBC): Hct concentration is elevated because inability to retain fluid results in hemoconcentration.

Gestational diabetes mellitus

● is an impaired tolerance to glucose with the first onset or recognition during pregnancy. The ideal blood glucose level during pregnancy should range between 70 and 110 mg/dL. ● Symptoms of diabetes mellitus can disappear a few weeks following delivery. However, approximately 50% of women will develop Type II diabetes mellitus within 5 years.